Health Technology Clinical Committee Findings and Decision

Topic: fusion - rereview Meeting date: June 18, 2021 Final adoption: July 9, 2021

Meeting materials and transcript are available on the HTA website.

Number and coverage topic: 20210618A – Sacroiliac joint fusion - rereview

HTCC coverage determination: In adults, 18 years old and older, with chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction, minimally invasive and open sacroiliac joint fusion procedures are not covered benefits.

Note - The scope of this decision does not apply to the following: • Low of other etiology (e.g., , neurogenic claudication), sacroiliac joint pain related to recent major trauma or fracture, infection, cancer, or sacroiliitis associated with inflammatory arthropathies; • Sacroiliac joint fusion revision surgery.

HTCC reimbursement determination: Limitations of coverage: N/A Non-covered indicators: N/A

Agency contact information:

Agency Phone Number Labor and Industries 1-800-547-8367 Public and School Employees Health Plan 1-800-200-1004 Washington State Medicaid 1-800-562-3022

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HTCC coverage vote and formal action: Committee decision Based on the deliberations of key health outcomes the committee decided that it had the most complete information: a comprehensive and current evidence report with updated literature since 2018, public comments, and state agency utilization information. The committee decided that the current evidence on sacroiliac joint fusion was sufficient to make a determination, discussed and voted on the evidence for the use of sacroiliac joint fusion. The committee considered the evidence, public comment and expert input, and gave greatest weight to the evidence it determined, based on objective factors, to be the most valid and reliable. Based on these findings, the committee voted to not cover minimally invasive or open sacroiliac joint fusion for sacroiliac chronic joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction for adults 18 years old and older. One committee member recused himself from the vote.

Covered under Covered Not covered certain conditions unconditionally Sacroiliac joint fusion - rereview 10 0 0

Discussion The committee reviewed and discussed the available studies for use of sacroiliac joint fusion for chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction. Details of study design, inclusion criteria, outcomes and other factors affecting study quality were discussed. A majority of committee members found the evidence sufficient to determine that use of sacroiliac joint fusion for chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction to be unproven for being safer, more effective, or more cost-effective than comparators.

Limitations N/A

Action The committee checked for availability of a Centers for Medicare and Medicaid Services (CMS) national coverage decision (NCD). There is no Medicare NCD for sacroiliac joint fusion for sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction at this time. The committee discussed clinical guidelines identified for sacroiliac joint fusion from the following organizations: • AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines: Sacroiliac Joint Fusion, (2020) • eviCore Clinical Guidelines Spine Surgery, (2020)

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• International Society for the Advancement of Spine Surgery International Society for the Advancement of Spine Surgery Policy 2020 Update—Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity, (2020) • North American Spine Society (NASS) Diagnosis and Treatment of , (2020) • National Institute for Health and Care Excellence (NICE) iFuse for treating chronic sacroiliac joint pain, (2018) • National Institute for Health and Care Excellence (NICE) Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain - Intervention Procedure Guidance 578, (2017)

The committee’s determination is not consistent with the noted guidelines. The HTCC determination included consideration of local, clinical expert considerations related to the complexities of revision surgeries, concerns related to diffusion, and uncertainty of evidence for safety and cost-effectiveness. The quality of evidence assessment was either not performed or not reported for these guidelines. The committee chair directed HTA staff to prepare a findings and decision document on use of sacroiliac joint fusion for public comment to be followed by consideration for final approval at the next committee meeting.

Health Technology Clinical Committee Authority: Washington State’s legislature believes it is important to use a science-based, clinician-centered approach for difficult and important health care benefit decisions. Pursuant to chapter 70.14 RCW, the legislature has directed the Washington State Health Care Authority (HCA), through its Health Technology Assessment (HTA) program, to engage in an evaluation process that gathers and assesses the quality of the latest medical evidence using a scientific research company that takes public input at all stages. Pursuant to RCW 70.14.110, a Health Technology Clinical Committee (HTCC) composed of eleven independent health care professionals reviews all the information and renders a decision at an open public meeting. The Washington State HTCC determines how selected health technologies are covered by several state agencies (RCW 70.14.080-140). These technologies may include medical or surgical devices and procedures, medical equipment, and diagnostic tests. HTCC bases its decisions on evidence of the technology’s safety, efficacy, and cost effectiveness. Participating state agencies are required to comply with the decisions of the HTCC. HTCC decisions may be re-reviewed at the determination of the HCA Director.

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